AAGL Meeting 2011 - Cindy Mosbrucker

Tamer Seckin, MD: Hi, this is one of our initiatives to support excision surgeons around the country. I have Cindy Mosbrucker from Washington. Cindy is an excisions surgeon trained by Dr. David Redwine, whose work we adore and is a good friend of ours. I would like to ask you a couple of questions. What are the challenges you have in your work environment with endometriosis patients and what do you envision as far as overcoming those challenges?

Cindy Mosbrucker, MD: That is a loaded question. The first challenge I think is that pain management specialists are very lacking in our area. For patients with just endometriosis related pain I do not need pain management specialists because I can remove their endometriosis and they feel so much better and they are so happy. But there is a small subset of our patients that have a neurogenic component to their pain, that they will still have pain after their excision. These may be some of the ladies that have had endometriosis for years and years and years and have allowed the central sensitization and up regulation of the peripheral nerves to proliferate. That is one challenge. Getting the word out and getting general gynaecologists to refer their patients to me even though they know they cannot do the surgery is kind of a challenge and it is the one thing that I would like to be able to influence somehow.

Tamer Seckin, MD: Let me ask you this, do you do anything if the patient comes back to you with pain after you have performed surgery and you do not feel any physical findings. She does not have any endometrioma; her pelvic exam does not reveal any nodules. But symptomatically she is believable and you already cleaned up endo from her. How do continue your care with that patient?

Cindy Mosbrucker, MD: I look for other sources of pain, bladder pain, interstitial cystitis, levator myalgia, levator spasm, other pelvic floor and external pelvic muscles like the psoas performance, those things can go into spasm. It just kind of depends on what their exam and what their symptoms are. Ninety-nine percent of the time they are legit and there is a real source of the pain. Maybe one percent of the time or two percent of the time there is really nothing that makes any sense.

Tamer Seckin, MD: At what time do you re-operate these patients?

Cindy Mosbrucker, MD: If I think it is related to endometriosis or something in the peritoneum, either adhesions, persistent cyst or potentially something that I missed, especially in a younger gal or somebody who has already had a surgically compromised…

Tamer Seckin, MD: Let me ask you this. Do you video tape your cases?

Cindy Mosbrucker, MD: Yes.

Tamer Seckin, MD: Do you think those videos help?

Cindy Mosbrucker, MD: You mean looking back to see if I missed something?

Tamer Seckin, MD: Of course.

Cindy Mosbrucker, MD: That would be a great idea to do that.

Tamer Seckin, MD: That is exactly what I do. We can share that info. I can share that because I video tape all my cases, endometriosis cases. I give a copy to the patient. First of all I want to be fair to her because I like to show her that I cleaned up as much as I could, what to do…visibility…resolution of my camera, my eyes but still at times, sometimes there are some endo even knowingly we leave. Simply because there is a point that you can only excise so much. You really think whatever you excise should have been enough. In those patients I really found out that even though you excise 90 percent, if you leave 10 percent, or five percent, watch that five percent because it can reactivate the same pain channel. It is not necessarily the amount of lesion; it is the disease that really transforms into pain. Pain is not really in the pelvis, pain is felt in the brain. The brain perceives the pain. I really do not hold my second surgery if the patient is on the same page with me because that video does help because many times those are myofascial and they are not really endoscopic issues. There are people, I respect their work, but in my opinion, second surgery should not be held because some of these times these patients do need second, at times third surgeries in a ten year period of time. And they do well in certain cases. We find that we have missed things. It is not easy to clean a disease that has destroyed things inside for 15 years. You can revert things in three hours of surgery, no matter who you are, in my opinion.

The second thing is when…do you start your patients on any oral contraceptive or medical treatment after excision surgery?

Cindy Mosbrucker, MD: It depends on how old they are and if they are trying to get pregnant or not. Obviously, if they want to get pregnant then I do not do that. If they are young and in a relationship and do not want to get pregnant then I think OCPs are a perfect solution. If they are in their 40s and we have done a hysterectomy and I have excised endometriosis then I do not routinely start them.

Tamer Seckin, MD: Do you have a team of surgeons that work with you who you call as endometriosis specialists, non-gynaecologists who would be on the same page with you and basically assist you and expedite the success of the surgery?

Cindy Mosbrucker, MD: Yes, since I train in urogynaecology do most of the bladder issues and ureteral issues, I feel more comfortable with that. I have a general surgeon who actually shares an office with me and she helps me with the bowel resections. Usually what I will do is the vast majority of the dissection and free everything up and then she will come in towards the end and to the reanastomosis.

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